, , ,


For Connor
For Sara and family
For all the dudes

Thanks to George Julian,
to all the #JusticeforLB team
to the Coronial service, to INQUEST.org.uk
and to the jury for their thorough, comprehensive and caring scrutiny.


13.36  The jury have returned to Court, but counsel are not here!  .  Coroner returns, everyone is here, the jury foreman stands.  The jury have reached a unanimous finding.

Name of deceased confirmed as Connor Sparrowhawk.

Connor died on 4 July 2013 at STATT.  No cardiac activity was detected with death pronounced at John Radcliffe Hospital.

Connor died as a result of drowning following a seizure in the bath, contributed to by neglect .

Lack of clinical leadership and lack of training and supervision; failure to conduct a history and conduct a risk assessment.  Inadequate communication with Connor’s family and between staff in relation to LB’s epilepsy needs and risks .

Was there a failure in the systems in place?  Yes, in training and guidance.  Too few staff were trained in epilepsy on the unit; training was too limited and insufficient on the unit.  Guidance was considered inadequate, the epilepsy toolkit was not provided to staff on STATT despite being available .  Lack of clinical leadership on the STATT unit .

Errors of omission to Connor’s care once admitted to STATT: bathing arrangements, full history shd been taken and informed a risk assessment.  Lack of communication with Connor’s family and missed opportunities to conduct a risk assessment.  Lack of communication with Connor’s family while he was on the unit.  Clinical team failed to identify a lack of epilepsy risk assessment plan .

Jury now asked to each sign the record of inquest .

Coroner: Only 1-2% of inquests have juries and thanks the jury for their service.

Coroner will make a report under Regulation 28 on the prevention of future deaths .  Prevention of Future Death report to will cover two areas:

First issue involves observations ; significant confusion amongst staff.  Coroner will focus particularly on inpatient obs re bathing and epilepsy, doesn’t share confidence around sight/sounds obs.  Clear guidelines from are required and clarity around what is meant in practice in relation to observations.  We’ve heard are not keen on full ban of bathing and Coroner does not recommend.  Will copy report to CQC for their comments.

2nd focus is RiO and epilepsy risk and training; there’s no designated place for relevant risk details.  We’ve heard toolkit is very good but need information to be accessible.  Focus also required on staff to be trained in how to use RiO and where to put relevant information.

STATT is closed.  Coroner is encouraged that there’s a process of signing off and validating CTMs now.  Coroner understands there have been changes to observation sheets.  Coroner: We’ve heard there is formal training at the Trust around communicating with families.

Coroner will continue to make enquiries into 2006 death of patient on STATT, may yet re-open that inquest; bears looking at in this context.  Coroner considers late disclosure concerning and will be writing to to seek an explanation; shd have been shared months ago.

Coroner offers his condolences to Connor’s family, friends and supporters.

Thanks offered by to members of the jury and the Coroner and Coroner’s officer .

14.00 The inquest is closed.